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Fanstone R, Price P. Global perspectives on risk factors for major joint burn contractures: A literature review. Burns 2024; 50:537-549. [PMID: 37977897 DOI: 10.1016/j.burns.2023.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/31/2023] [Accepted: 09/22/2023] [Indexed: 11/19/2023]
Abstract
Contractures are a frequent consequence of burn injuries, yet our knowledge of associated risk factors is limited. This paper provides an extensive review of relevant literature from both High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). Ninety-four papers (up to June 2019) and eight subsequent publications (up to March 2022) were included, 76% of which were from HICs. The majority of publications were either descriptive studies (4 from HICs, 9 from LMICs) or papers citing putative risk factors (37 from HICs, 10 from LMICs). Seventeen publications (all from HICs) reported on the effects of individual non-surgical therapeutic interventions, often with conflicting results. Two published systematic reviews emphasised the poor quality of evidence available. Only fifteen studies (3 from LMICs) examined potential contracture risk factors with statistical comparisons of outcomes; significant findings from these included demographic, burn, comorbidities, and treatment risk factors. LMIC papers included socioeconomic and healthcare system factors as potential risks for contracture; these were rarely considered in HIC publications. Methodological issues identified from this review of literature included differences in contracture definitions, populations studied, standards of care, joints included and the timing and nature of contracture assessments.This review is the first to collate existing knowledge on risk factors for burn contractures from both HIC and LMIC settings, revealing a surprising lack of robust evidence for many accepted risk factors. In LMICs, where burns are particularly common, universal health provision is lacking and specialist burn care is both scarce and difficult to access; consequently, socioeconomic factors may have more immediate impact on contracture outcomes than specific burn treatments or therapies. Much more work is indicated to fully understand the relative impacts of risk factors in different settings so that context-appropriate contracture prevention strategies can be developed.
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Affiliation(s)
- RuthAnn Fanstone
- Centre for Global Burn Injury Policy and Research, Swansea University, UK.
| | - Patricia Price
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
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Blome-Eberwein SA, Schwartz A, Ferdock M, Starner S, Gogal C. Minimally invasive burn reconstruction with subcutaneous scar contracture release. Burns 2024:S0305-4179(24)00094-9. [PMID: 38609745 DOI: 10.1016/j.burns.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Scar contracture bands after burns are frequent problems that cause discomfort and physical limitation. This study investigates the efficacy of a minimally invasive contracture band release technique (MICBR) inspired by closed platysmotomy. METHODS Patients with burn scars treated with MICBR in our center were included retrospectively. Our routine scar and contracture treatments (non-invasive and invasive) were utilized prior to undergoing MICBR. Range of motion (ROM) and Vancouver Scar Scale was measured before and after the procedure when feasible. RESULTS Forty-five patients were included, with 97 total contracture sites treated all over the body. An average of 1.6 sites were treated per patient, with a maximum of six. Patients age was 6-68 years; total burn surface area ranged from 0.5% to 85%. 24% were performed under local anesthesia. 84% were in originally skin grafted areas. We found significant improvements in ROM and VSS. 84% of patients surveyed were "satisfied" or "very satisfied". 95% reported improved mobility. No significant adverse events occurred. CONCLUSION This MICBR technique is a versatile, safe, and well-tolerated adjunct procedure that can help patients regain mobility after a burn injury.
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Affiliation(s)
- Sigrid A Blome-Eberwein
- Department of Surgery, Division of Burn Surgery, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Adam Schwartz
- Department of Surgery, Division of Burn Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | | | - Sophia Starner
- Department of Surgery, Division of Burn Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | - Christina Gogal
- Network Office of Research and Innovation, Lehigh Valley Health Network, Allentown, PA, USA
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Fanstone R, Price P, Bodger O, Potokar T, Khan MRK. Risk factors for burn contractures: A cross-sectional study in a lower income country. Burns 2024; 50:454-465. [PMID: 37980272 DOI: 10.1016/j.burns.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/31/2023] [Accepted: 09/09/2023] [Indexed: 11/20/2023]
Abstract
Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.
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Affiliation(s)
- RuthAnn Fanstone
- Centre for Global Burn Injury Policy and Research, Swansea University, UK.
| | - Patricia Price
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
| | - Owen Bodger
- Faculty of Medicine, Health and Life Sciences, Swansea University, UK
| | - Tom Potokar
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
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Fanstone R, Price P. Burn contracture risk factors and measurement in low-middle income countries: A clinical perspective. Burns 2024; 50:466-473. [PMID: 37985269 DOI: 10.1016/j.burns.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/31/2023] [Accepted: 09/12/2023] [Indexed: 11/22/2023]
Abstract
We find a lack of high-quality published evidence on risk factors for burn contracture formation. The vast majority of research is from High Income Countries (HICs), where many potential risk factors are controlled for by standardised and high-quality healthcare systems. To augment the published literature, burn care professionals with Low Middle Income Countries (LMICs) experience were interviewed for their opinion on risk factors for burn contracture formation. Participants were also asked for their views on identification and measurement of contracture. Seventeen semi-structured interviews were conducted (13 burn surgeons and 4 therapists). The average length of experience in burn-care was 13 years. Participants represented Ghana, Ethiopia, Malawi, Nigeria, South Africa, Nepal, and India. Participants reported ninety risk factors. Risk factors were later collated according to topic: Non burn individual factors (n = 13), Burn injury factors (n = 14), Family and community factors (n = 9), Treatment factors (n = 18), Complications (n = 2), Healthcare capacity factors (n = 19) and Societal and environmental factors (n = 12). The top five most frequently cited risk factors were lack of splinting, lack of physiotherapy, lack of early excision and skin grafting, low socioeconomic status and presence of infection. Although participants had no doubts that they could recognise a contracture, none provided a standardised system of measurement or an operational definition of contracture. Burn care professionals have a wealth of experience and untapped knowledge of risk factors for burn contracture formation in their own population base, but many of the risk factors highlighted by participants have not yet been explored in the literature. Variations in clinicians' diagnosis and measurement of a burn contracture underscores the need for an agreed, standardised, simple and easily reproducible method of diagnosing and classifying burn contractures.
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Affiliation(s)
- RuthAnn Fanstone
- Centre for Global Burn Injury Policy and Research, Swansea University, UK.
| | - Patricia Price
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
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Ergani HM, Yalçın Topçuoğlu E, Yaşar B, Akgün AE, Acicbe O, Akın M, Erkin Ünlü R, Yastı AÇ. Physical Medicine Applications in Hand Burns: Treatment or Rehabilitation. J Burn Care Res 2024; 45:98-103. [PMID: 37638523 DOI: 10.1093/jbcr/irad130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Indexed: 08/29/2023]
Abstract
The aim of this study is to investigate the contribution of concurrent physical therapy to the preservation of hand function in patients with hand burns. This retrospective cohort study included the records of adult patients who presented with hand burns between July 1, 2020, and December 1, 2021. A total of 67 of 1578 burn patients who attended the clinic were included in this study. The patients' age, sex, total BSA with burns, causative agent, depth of burn on the hand, right or left hand, location of the burned area on the hand, treatment applied, healing time of the burn on the hand, limitation of movement, the joint restrictions, contractures, and compliance with physical therapy were assessed and recorded. Among the 67 patients included, 82.1% (n = 55) had no limitation in terms of their joint range of motion, whereas 17.9% (n = 12) had a limitation of movement in their finger joints. When the prevalence of movement limitation was examined by gender, such limitation was found to be more common in females (P = .041). Moreover, contractures were found to occur more frequently in patients with full-thickness burns (P = .032). It was also found that the limitation of movement was more severe in patients with skin grafts (P = .044). In addition, it was observed that the recovery time of the burn area was longer in those patients who had movement limitations (P = .004). In this study, we found that applying early physical therapy to patients after burn injuries facilitated the recovery of hand functions.
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Affiliation(s)
- Hasan Murat Ergani
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Elif Yalçın Topçuoğlu
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Burak Yaşar
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ali Emre Akgün
- Department of General Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Okan Acicbe
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Merve Akın
- Department of General Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ramazan Erkin Ünlü
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Çınar Yastı
- Department of General Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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Rowe G, Allahham A, Edgar DW, Rurak BK, Fear MW, Wood FM, Vallence AM. Functional Brain Changes Following Burn Injury: A Narrative Review. Neurorehabil Neural Repair 2024; 38:62-72. [PMID: 38044625 PMCID: PMC10798013 DOI: 10.1177/15459683231215331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Burn injuries cause significant motor and sensory dysfunctions that can negatively impact burn survivors' quality of life. The underlying mechanisms of these burn-induced dysfunctions have primarily been associated with damage to the peripheral neural architecture, however, evidence points to a systemic influence of burn injury. Central nervous system (CNS) reorganizations due to inflammation, afferent dysfunction, and pain could contribute to persistent motor and sensory dysfunction in burn survivors. Recent evidence shows that the capacity for neuroplasticity is associated with self-reported functional recovery in burn survivors. OBJECTIVE This review first outlines motor and sensory dysfunctions following burn injury and critically examines recent literature investigating the mechanisms mediating CNS reorganization following burn injury. The review then provides recommendations for future research and interventions targeting the CNS such as non-invasive brain stimulation to improve functional recovery. CONCLUSIONS Directing focus to the CNS following burn injury, alongside the development of non-invasive methods to induce functionally beneficial neuroplasticity in the CNS, could advance treatments and transform clinical practice to improve quality of life in burn survivors.
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Affiliation(s)
- Grant Rowe
- School of Psychology, College of Health and Education, Murdoch University, Murdoch, WA, Australia
| | - Amira Allahham
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA, Australia
| | - Dale W. Edgar
- Fiona Wood Foundation, Murdoch, WA, Australia
- Burn Service of Western Australia, Fiona Stanley Hospital, MNH (B) Main Hospital, Level 4, Burns Unit, Murdoch, WA, Australia
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Brittany K. Rurak
- School of Psychology, College of Health and Education, Murdoch University, Murdoch, WA, Australia
| | - Mark W. Fear
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA, Australia
- Fiona Wood Foundation, Murdoch, WA, Australia
| | - Fiona M. Wood
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA, Australia
- Fiona Wood Foundation, Murdoch, WA, Australia
- Burn Service of Western Australia, Fiona Stanley Hospital, MNH (B) Main Hospital, Level 4, Burns Unit, Murdoch, WA, Australia
| | - Ann-Maree Vallence
- School of Psychology, College of Health and Education, Murdoch University, Murdoch, WA, Australia
- Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch, WA, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, WA, Australia
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Litmanovich B, Alizai Q, Stewart C, Hosseinpour H, Nelson A, Bhogadi SK, Colosimo C, Spencer AL, Ditillo M, Joseph B. Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in? J Surg Res 2024; 293:327-334. [PMID: 37806218 DOI: 10.1016/j.jss.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/02/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Frailty has been known to negatively affect the outcomes of geriatric trauma patients. However, there is a lack of data on the effect of frailty on the outcomes of geriatric trauma patients with concomitant burn injuries. The aim of our study was to compare the outcomes of frail versus nonfrail geriatric trauma patients with concomitant burn injuries. METHODS We performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS A total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median [interquartile range] ISS was 3[1-10]. Overall, the rate of mortality was 23% and median hospital LOS was 14[3-31]. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001). CONCLUSIONS Among geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.
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Affiliation(s)
- Ben Litmanovich
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Godleski M, Yelvington M, Jean S. Burn Injury Complications Impacting Rehabilitation. Phys Med Rehabil Clin N Am 2023; 34:799-809. [PMID: 37806698 DOI: 10.1016/j.pmr.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.
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Affiliation(s)
- Matthew Godleski
- Department of Physical Medicine and Rehabilitation, Sunnybrook Health Sciences Centre, University of Toronto, St. John's Rehab, 285 Cummer Avenue, Toronto, Ontario M2M 2G1, Canada.
| | - Miranda Yelvington
- Department of Rehabilitation, Arkansas Children's Hospital, 1 Children's Way, Slot 104, Little Rock, AR 72202, USA
| | - Stephanie Jean
- Department of Physical Medicine and Rehabilitation, Institut de Réadaptation Gingras-Lindsay de Montréal (Darlington), Université de Montréal, 6300 Avenue Darlington, Montréal, Québec H3S 2J4, Canada
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Li R, Zheng Y, Fan X, Cao Z, Yue Q, Fan J, Gan C, Jiao H, Liu L. Establishment and validation of a nomogram to predict the neck contracture after skin grafting in burn patients: A multicentre cohort study. Int Wound J 2023; 20:3648-3656. [PMID: 37245866 PMCID: PMC10588345 DOI: 10.1111/iwj.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/30/2023] Open
Abstract
Cervical burn contracture is one of the burn contractures with the highest incidence and severity, and there is no effective method to predict the risk of neck contracture. This study aimed to investigate the effect of combined cervicothoracic skin grafting on the risk of neck contracture in burn patients and to develop a nomogram to predict the risk of neck contracture after skin grafting in burn patients. Data from 212 patients with burns who underwent neck skin grafting were collected from three hospitals, and the patients were randomly divided into training and validation sets. Independent predictors were identified through univariate and multivariate logistic regression analyses and incorporated into a prognostic nomogram. Its performance was assessed using the receiver operating characteristic area under the curve, calibration curve, and decision curve analysis. Burn depth, combined cervicothoracic skin grafting, graft thickness, and neck graft size were significantly associated with neck contractures. In the training cohort, the nomogram had an area under the curve of 0.894. The calibration curve and decision curve analysis indicated good clinical applicability of the nomogram. The results were tested using a validation dataset. Combined cervicothoracic skin grafting is an independent risk factor for neck contracture. Our nomogram demonstrated excellent performance in predicting neck contracture risk.
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Affiliation(s)
- Rui Li
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Yangyang Zheng
- Department of General Surgery, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Xijuan Fan
- Department of Plastic SurgeryBeijing Ever Care Medical and Beauty HospitalBeijingChina
| | - Zilong Cao
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Qiang Yue
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Jincai Fan
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Cheng Gan
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Hu Jiao
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Liqiang Liu
- Scar and Wound Treatment CenterPlastic Surgery Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
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Yelvington ML, Parry I. Integration of Cutaneous Functional Units Principles in Burn Rehabilitation: A Diffusion of Innovations Assessment. J Burn Care Res 2023; 44:1134-1139. [PMID: 36688492 DOI: 10.1093/jbcr/irad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Indexed: 01/24/2023]
Abstract
Early recognition of contractures can lead to a more targeted therapy regimen, potentially preventing range of motion losses and improving function and quality of life. Cutaneous functional units (CFUs) allow therapists to explain motion limitations and formulate patient-specific treatment plans. Evidence-based research demonstrates the potential of using these principles to improve the current standard of care. Still, the consistent use of these principles has been slow to diffuse through burn care. Occupational and physical therapists were surveyed to determine the degree to which CFU principles are being integrated into clinical practice. Respondents (297) were occupational therapists (52%) and physical therapists (49%) working in burn units (81%) in North America (70.7%). Most respondents (78.4%) report familiarity with CFU principles. Of those familiar, most respondents reported their knowledge (66.7%) and ability to apply (65.7%) at an intermediate level or greater. A slight majority (59.3%) responded that the concepts influenced their practice, while 40.7% said the concepts did not influence their practice. Forty percent to sixty-nine percent of respondents correctly answered knowledge questions, but only 15% of respondents correctly completed CFUs identification questions. Respondents (77%) report barriers, including difficulty incorporating into practice, time constraints, and the need for more education. Results suggest that diffusion can be improved by developing tools to assist therapists in understanding and incorporating CFUs' principles.
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Affiliation(s)
| | - Ingrid Parry
- University of California, Davis, 2425 Stockton Blvd. Sacramento, CA 95817, USA
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11
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Li R, Zheng Y, Fan X, Cao Z, Yue Q, Fan J, Gan C, Jiao H, Liu L. Epidemiology and Predictors for Cervical Burn Scar Contractures: A Multicenter Cohort Study. J Craniofac Surg 2023; 34:1795-1798. [PMID: 37184463 DOI: 10.1097/scs.0000000000009344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/20/2023] [Indexed: 05/16/2023] Open
Abstract
Cervical burn scar contracture (BSC) affects many important neck functions and the patients' quality of life. However, it remains unclear which patients have a higher risk of neck BSCs. This study aimed to describe the epidemiology and identify the independent risks of cervical BSC formation and severity. Clinical and demographic data of 106 patients with burn scars were retrospectively collated and analyzed from 3 different Chinese hospitals between December 2016 and December 2020. Both univariate and multivariate logistic regression analyses were performed to identify the independent risks for BSC formation and severity at 12 months postburn. Lateral flexion was the most common plane of motion (POM) limited by contractures (29.4%), whereas the POM most commonly limited by severe contractures was the extension (24.6%). Most patients with contractures had those in 3 to 4 POMs (72.1%). Neck skin grafting was an independent risk factor for BSC formation, and cervical and cervicothoracic skin grafting were independent risk factors for BSC severity. These results may help to identify high-risk patients with contractures in the early stages of burns to carry out individualized early prevention and treatment.
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Affiliation(s)
- Rui Li
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yangyang Zheng
- Department of General Surgery, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xijuan Fan
- Department of Plastic Surgery, Beijing Ever Care Medical and Beauty Hospital, Beijing, China
| | - Zilong Cao
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Yue
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jincai Fan
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Cheng Gan
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Jiao
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liqiang Liu
- 9th Department, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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12
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Haidary A, Hoellwarth JS, Tetsworth K, Oomatia A, Al Muderis M. Transcutaneous osseointegration for amputees with burn trauma. Burns 2023; 49:1052-1061. [PMID: 36907716 DOI: 10.1016/j.burns.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/14/2023] [Accepted: 02/19/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Transcutaneous osseointegration for amputees (TOFA) surgically implants a prosthetic anchor into the residual limb's bone, enabling direct skeletal connection to a prosthetic limb and eliminating the socket. TOFA has demonstrated significant mobility and quality of life benefits for most amputees, but concerns regarding its safety for patients with burned skin have limited its use. This is the first report of the use of TOFA for burned amputees. METHODS Retrospective chart review was performed of five patients (eight limbs) with a history of burn trauma and subsequent osseointegration. The primary outcome was adverse events such as infection and additional surgery. Secondary outcomes included mobility and quality of life changes. RESULTS The five patients (eight limbs) had an average follow-up time of 3.8 ± 1.7 (range 2.1-6.6) years. We found no issues of skin compatibility or pain associated with the TOFA implant. Three patients underwent subsequent surgical debridement, one of whom had both implants removed and eventually reimplanted. K-level mobility improved (K2 +, 0/5 vs 4/5). Other mobility and quality of life outcomes comparisons are limited by available data. CONCLUSION TOFA is safe and compatible for amputees with a history of burn trauma. Rehabilitation capacity is influenced more by the patient's overall medical and physical capacity than their specific burn injury. Judicious use of TOFA for appropriately selected burn amputees seems safe and merited.
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Affiliation(s)
- Amanullah Haidary
- Western Sydney University School of Medicine, Building 30 Campbelltown Campus, Campbelltown, NSW, Australia.
| | - Jason S Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia.
| | - Atiya Oomatia
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia.
| | - Munjed Al Muderis
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia.
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Cancio JM, Dewey WS. Critical Care Rehabilitation of the Burn Patient. Surg Clin North Am 2023; 103:483-494. [PMID: 37149384 DOI: 10.1016/j.suc.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.
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Affiliation(s)
- Jill M Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass Suite B, JBSA Fort Sam Houston, TX 78234-7767, USA.
| | - William S Dewey
- US Army Institute of Surgical Research, 3698 Chambers Pass Suite B, JBSA Fort Sam Houston, TX 78234-7767, USA
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Bryarly J, Kowalske K. Long-Term Outcomes in Burn Patients. Surg Clin North Am 2023; 103:505-513. [PMID: 37149386 DOI: 10.1016/j.suc.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Better understanding of long-term outcomes after burn injury is essential for the burn clinician. Contractures are present in almost half of patients at discharge. Although less common, neuropathy and heterotopic ossification may be missed or go unaddressed. Close attention to psychological distress and to challenges with community reentry is essential. Obviously long-term problems with skin issues occur but other issues must be attended to maximize health and quality of life after injury. Facilitating access to community resources and providing long-term medical follow-up should be the standard of care.
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Affiliation(s)
- Julia Bryarly
- Physical Medicine and Rehabilitation, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9055, USA
| | - Karen Kowalske
- Physical Medicine and Rehabilitation, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9055, USA.
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Management of Severe Extended Burn Axillary Contracture in a Low-resource Setting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4893. [PMID: 36923714 PMCID: PMC10010848 DOI: 10.1097/gox.0000000000004893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/03/2023] [Indexed: 03/14/2023]
Abstract
Contracture is a common complication of deep burn injury, affecting up to one-third of patients. Although some degree of contracture occurs in any setting, severe extended axillary contractures are more often due to unavailable or inappropriate care. Very few cases have been described in the literature. Their management can be especially challenging in a low-resource environment. The purpose of this article is to present two cases in which severe postburn axillary contractures were effectively managed in a low resource setting, using an island perforator flap coupled with a skin graft or advancement flap. In severe extended axillary contracture, more than one technique is often required to cover the large defect created after contracture release.
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McNamara CT, Iorio ML, Greyson M. Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury. Front Surg 2023; 10:1118810. [PMID: 37206342 PMCID: PMC10188946 DOI: 10.3389/fsurg.2023.1118810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/12/2023] [Indexed: 05/21/2023] Open
Abstract
Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.
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17
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Ahn KJ, Kim JS. TGF-β1 upregulates Sar1a expression and induces procollagen-I secretion in hypertrophic scarring fibroblasts. Open Med (Wars) 2022; 17:1473-1482. [PMID: 36188194 PMCID: PMC9483117 DOI: 10.1515/med-2022-0543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022] Open
Abstract
Hypertrophic scarring (HTS) is a common fibroproliferative disorder that typically follows thermal and other injuries involving the deep dermis. The underlying pathogenic mechanisms are regulated by transforming growth factor-β (TGF-β); however, the exact mechanisms in HTS have not been elucidated. We conducted this study to explore the cellular signaling mechanisms for expression of Sar1a, a coat protein complex II-associated small GTPase, in HTS fibroblasts (HTSF). We found that Sar1a was upregulated in HTSF as compared to that in normal fibroblasts. Furthermore, stimulation of TGF-β1 increased the expression of Sar1a in HTSF, and small interfering RNA for Sar1a suppressed procollagen-I (PC-I) secretion. Next we investigated the signaling mechanism from TGF-β1 to Sar1a expression and its association with PC-I secretion. In the presence of TGF-β-activated kinase 1 (TAK1), c-Jun N-terminal kinase, or p38 inhibitors, the effect of TGF-β1 on Sar1a expression and PC-I secretion significantly decreased; however, it had no effect on collagen-1A (Col-1A) expression. Further, the inhibitors of Smad3 or extracellular signal-regulated kinases inhibited TGF-β1-induced Col-1A expression but had no effect on PC-I secretion and Sar1a expression. Taken together, our results suggested that TGF-β1 induces Sar1a expression through TAK1 signaling and this signaling event regulates PC-I secretion in HTSF.
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Affiliation(s)
- Keun Jae Ahn
- Department of Science Education, Jeju National University, Jeju, 63063, Korea
| | - Jun-Sub Kim
- Department of Biotechnology, Korea National University of Transportation, Chungbuk, 27909, Korea
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18
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Resnik L, Borgia M, Cancio J, Heckman J, Highsmith MJ, Levy C, Phillips S, Webster J. Understanding Implications of Residual Limb Length, Strength, and Range-of-Motion Impairments of Veterans With Upper Limb Amputation. Am J Phys Med Rehabil 2022; 101:545-554. [PMID: 34347631 DOI: 10.1097/phm.0000000000001862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to describe and quantify the relationship between limb impairment variables to key functional outcomes. DESIGN This was an observational study of 107 participants with unilateral above/at-elbow or below-elbow/wrist amputation. Demographics, prosthesis characteristics, residual limb length, and prevalence of passive range-of-motion restrictions, and strength impairments were described. Correlations between impairment variables were estimated. Linear regressions examined associations between impairment variables and activity performance, health-related quality of life, disability, and prosthesis satisfaction. RESULTS Prevalence of short/very short below- and above-elbow residua was 25.7% and 12.5%, respectively. Shorter below-elbow/wrist residual limb length was correlated with elbow flexion weakness (r = 0.30) and prevalence of passive range of motion (r = 0.25). Shoulder prevalence of passive range-of-motion restrictions were correlated with shoulder (r = 0.27-0.51) and elbow weakness (r = 0.25-0.46). In regressions, activity performance was worse for those with shoulder flexion prevalence of passive range-of-motion restrictions (B = -5.0, P = 0.03) and better for those with flexion restrictions (B = 3.3, P = 0.04) compared with normal prevalence of passive range of motion. Prosthetic satisfaction was lower for those with limited elbow prevalence of passive range of motion. CONCLUSIONS Short below-elbow residual limb length was correlated with impairment of elbow flexion strength and prevalence of passive range of motion. Prevalence of passive range-of-motion restrictions were most prevalent at the shoulder and were strongly correlated with weakness in the same planes of motion. Few significant associations were found between impairment variables and outcomes.
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Affiliation(s)
- Linda Resnik
- From the Research Department, Providence VA Medical Center, Providence, Rhode Island (LR, MB); Health Services, Policy and Practice, Brown University, Providence, Rhode Island (LR); US Army Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, Texas (JC); Physical Medicine and Rehabilitation Services, James A. Haley Veterans' Hospital & Clinics, Tampa, Florida (JH); Physical Medicine and Rehabilitation Department, University of South Florida, Tampa, Florida (JH); Rehabilitation & Prosthetic Services (10P4R), Orthotic, Prosthetic & Pedorthic Clinical Services, US Department of Veterans Affairs, Washington, DC (MJH); School of Physical Therapy & Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida (MJH); Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida (CL); James A. Haley VA Hospital, Tampa, Florida (SP); Department of Physical Medicine and Rehabilitation, School of Medicine at Virginia Commonwealth University, Richmond, Virginia (JW); and Physical Medicine and Rehabilitation, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia (JW)
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19
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Jeong WJ, Holavanahalli RK, Kowalske KJ. Evaluation of Kinesiophobia in Survivors of Major Burn Injury. J Burn Care Res 2022; 43:1380-1385. [PMID: 35385580 DOI: 10.1093/jbcr/irac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Kinesiophobia, the fear of movement and re-injury, has not been described in burn injury survivors. Physical activity is a key component of burn rehabilitation programs. Yet, not all burn survivors exercise at the recommended level. This is an exploratory study examining the association of the demographics and injury characteristics of burn survivors with a fear of movement. The subjective fear of movement was measured using the Tampa Scale for Kinesiophobia (TSK). The TSK score was compared between several demographics and injury characteristics by performing the independent sample t-test. Sixty-six percent of subjects in our study (n=35), reported high levels of kinesiophobia (score 37 or above). The mean scores of the TSK were greater in males (40.7), non-White (43.0), Hispanic/Latino (41.1), age greater than 50 years (42.3), and total body surface area (TBSA) burn of >15% compared to females (36.9), White (38.5), non-Hispanic/Latino (39.3), age 50 years or less (38.1), and TBSA 15% or less (39.4) respectively. However, with the exception of time post injury, none of the mean differences were statistically significant. Subjects who had sustained a burn injury more than 12 months ago showed higher levels of kinesiophobia than the subjects who were injured within 12 months with a mean difference of 7.35 (p=.01). Thus, this study highlights the importance of (i) continued, long-term follow up for burn survivors, and (ii) appropriate educational and treatment interventions to address any underlying existing, new, or emerging medical issues that may contribute to the fear or avoidance of movement.
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Affiliation(s)
- Won J Jeong
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Radha K Holavanahalli
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Karen J Kowalske
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, U.S.A
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20
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Schouten HJ, Nieuwenhuis MK, van Baar ME, van der Schans CP, Niemeijer AS, van Zuijlen PPM. The degree of joint range of motion limitations after burn injuries during recovery. Burns 2022; 48:309-318. [PMID: 34955294 DOI: 10.1016/j.burns.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The aim of this study was to determine the degree of ROM limitations of extremities, joints and planes of motion after burns and its prevalence over time. METHOD The database of a longitudinal multicenter cohort study in the Netherlands (2011-2012) was used. From patients with acute burns involving the neck, shoulder, elbow, wrist, hip, knee and ankle joints that had surgery, ROM of 17 planes of motion was assessed by goniometry at 3, 6 weeks, 3-6-9 and 12 months after burns and at discharge. RESULTS At 12 months after injury, 12 out of 17 planes of motion demonstrated persistent joint limitations. The five unlimited planes of motion were all of the lower extremity. The most severely limited joints at 12 months were the neck, ankle, wrist and shoulder. The lower extremity was more severely limited in the early phase of recovery whereas at 12 months the upper extremity was more severely limited. CONCLUSION The degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. This study showed which joints and planes of motion should be watched specifically concerning the development of scar contracture.
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Affiliation(s)
- H J Schouten
- Association of Dutch Burn Centers, Burn Centre, Red Cross Hospital Beverwijk, The Netherlands; Burn Centre and Dept of Plastic & Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Department of Physiotherapy, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Science's Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands.
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Centre, Martini Hospital Groningen, The Netherlands; Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands
| | - M E van Baar
- Association of Dutch Burn Centers, Burn Centre, Maasstad Hospital Rotterdam, The Netherlands; Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - C P van der Schans
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences Groningen, The Netherlands; Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, The Netherlands; Health Psychology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn Centre, Martini Hospital Groningen, The Netherlands; Research Institute, Martini Hospital Groningen, The Netherlands
| | - P P M van Zuijlen
- Burn Centre and Dept of Plastic & Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Science's Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands; Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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21
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Li J, Ng SKH, Xi W, Zhang Z, Wang X, Li H, Su W, Wang J, Zhang Y. Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model. BURNS & TRAUMA 2022; 9:tkab048. [PMID: 34988232 PMCID: PMC8720306 DOI: 10.1093/burnst/tkab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fractional CO2 laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode. METHODS A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling. RESULTS A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks. CONCLUSIONS Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.
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Affiliation(s)
- Jie Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Sally Kiu-Huen Ng
- Department of Plastic Surgery, Austin Health, Melbourne 3084, Australia.,Victorian Adult Burns Service, Alfred Health, Melbourne 3181, Australia
| | - Wenjing Xi
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xiaodian Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Hua Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Weijie Su
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Jingyan Wang
- Department of Plastic and Reconstructive Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
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22
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Chen L, Li Z, Zheng Y, Zhou F, Zhao J, Zhai Q, Zhang Z, Liu T, Chen Y, Qi S. 3D-printed dermis-specific extracellular matrix mitigates scar contraction via inducing early angiogenesis and macrophage M2 polarization. Bioact Mater 2021; 10:236-246. [PMID: 34901542 PMCID: PMC8636711 DOI: 10.1016/j.bioactmat.2021.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/21/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022] Open
Abstract
Scar contraction frequently happens in patients with deep burn injuries. Hitherto, porcine dermal extracellular matrix (dECM) has supplied microenvironments that assist in wound healing but fail to inhibit scar contraction. To overcome this drawback, we integrate dECM into three-dimensional (3D)-printed dermal analogues (PDA) to prevent scar contraction. We have developed thermally gelled, non-rheologically modified dECM powder (dECMp) inks and successfully transformed them into PDA that was endowed with a micron-scale spatial structure. The optimal crosslinked PDA exhibited desired structure, good mechanical properties as well as excellent biocompatibility. Moreover, in vivo experiments demonstrated that PDA could significantly reduced scar contraction and improved cosmetic upshots of split thickness skin grafts (STSG) than the commercially available dermal templates and STSG along. The PDA has also induced an early, intense neovascularization, and evoked a type-2-like immune response. PDA's superior beneficial effects may attribute to their desired porous structure, the well-balanced physicochemical properties, and the preserved dermis-specific ECM cues, which collectively modulated the expression of genes such as Wnt11, ATF3, and IL1β, and influenced the crucial endogenous signalling pathways. The findings of this study suggest that PDA is a clinical translatable material that possess high potential in reducing scar contraction. Current dermal analogues have supplied microenvironments that assist in wound healing but cannot inhibit scar contraction. dECMp ink was formulated and transformed into PDA endowed with a micron-scale designed spatial structure. The PDAs were neatly superior to split thickness skin grafts and commercial dermal templates in hindering scar contraction. The transcriptome data may reveal how at the molecular level the IS and skin wounds respond to biomaterial stimuli.
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Affiliation(s)
- Lei Chen
- Department of Burns, Laboratory of General Surgery, The First Affiliated Hospital, SunYat-Sen University, Guangzhou, 510080, China
| | - Zhiyong Li
- School of Materials Science and Engineering, Centre of Functional Biomaterials, Key Laboratory of Polymeric Composite Materials and Functional Materials of Ministry of Education, GD Research Centre for Functional Biomaterials Engineering and Technology, Sun Yat-sen University, Guangzhou, 510275, China
| | - Yongtai Zheng
- School of Materials Science and Engineering, Centre of Functional Biomaterials, Key Laboratory of Polymeric Composite Materials and Functional Materials of Ministry of Education, GD Research Centre for Functional Biomaterials Engineering and Technology, Sun Yat-sen University, Guangzhou, 510275, China
| | - Fei Zhou
- Department of Burns, Laboratory of General Surgery, The First Affiliated Hospital, SunYat-Sen University, Guangzhou, 510080, China
| | - Jingling Zhao
- Department of Burns, Laboratory of General Surgery, The First Affiliated Hospital, SunYat-Sen University, Guangzhou, 510080, China
| | - Qiyi Zhai
- Department of Burns, Laboratory of General Surgery, The First Affiliated Hospital, SunYat-Sen University, Guangzhou, 510080, China
| | - Zhaoqiang Zhang
- Department of Oral and Maxillofacial Surgery, Stomatological Hospital, Southern Medical University, No. 366, South of Jiangnan Boulevard, Guangzhou, 510280, China
| | - Tianrun Liu
- Department of Otorhinolaryngology Head and Neck Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongming Chen
- School of Materials Science and Engineering, Centre of Functional Biomaterials, Key Laboratory of Polymeric Composite Materials and Functional Materials of Ministry of Education, GD Research Centre for Functional Biomaterials Engineering and Technology, Sun Yat-sen University, Guangzhou, 510275, China
| | - Shaohai Qi
- Department of Burns, Laboratory of General Surgery, The First Affiliated Hospital, SunYat-Sen University, Guangzhou, 510080, China
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Chaudhary FA, Ahmad B, Sinor MZ. The severity of facial burns, dental caries, periodontal disease, and oral hygiene impact oral health-related quality of life of burns victims in Pakistan: a cross-sectional study. BMC Oral Health 2021; 21:570. [PMID: 34749722 PMCID: PMC8573980 DOI: 10.1186/s12903-021-01923-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/18/2021] [Indexed: 02/03/2023] Open
Abstract
Background A burn to the face and neck area leaves a visible scar that impacts the victims physically and psychologically. This report was aimed to examine the factors associated with oral health-related quality of life (OHRQoL) in patients with a facial burn injury. Methods Patients with facial burn who attended the Burn Care Centre in Islamabad, Pakistan were systematically and randomly invited to participate in this cross-sectional study. They underwent extra- and intra-oral examinations and, completed self-administered instruments in the Urdu language. The severity of disfigurement, dental caries experience (DMFT), periodontal disease (CPI) and oral hygiene (OHI-S) statuses were assessed. The validated instruments collected information relating to sociodemographic background, oral health behaviours, OHRQoL and satisfaction with appearance (SWAP). Information relating to the time of the incident, cause and severity (type, TBSA) of the burn were obtained from medical records. The OHRQoL prevalence of impact and severity measures were derived and analysed using simple and multiple, logistic and linear regression. Results A total of 271 patients had participated in the study. The OHIP-14 prevalence of impact was 94% with mean severity score = 37 unit (sd = 8.5). The most impacted domains were physical pain (87%), psychological disability (87%), social disability (85%) and physical discomfort (83%). The main determinants of oral health-related quality of life were poor clinical oral conditions - particularly caries, and severity deformity. Other risk factors included poor oral health behaviours, psychological distress and longer time elapsed since the incident, and sex (p < 0.05). Conclusion Dental caries, the severity of the facial deformity, oral health behaviour and time are associated with oral health-related quality of life of patients with facial burns. Oral health behaviour improvement can lower the risk of developing dental problems and oral health-related quality of life impact.
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Affiliation(s)
- Farooq Ahmad Chaudhary
- School of Dentistry, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
| | - Basaruddin Ahmad
- School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.
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24
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The use of Matriderm for penile reconstruction: a case series. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Angelou IK, van Aswegen H, Wilson M, Grobler R. A profile of adult patients with major burns admitted to a Level 1 Trauma Centre and their functional outcomes at discharge: A retrospective review. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2021. [DOI: 10.4102/sajp.v77i1.1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Li T, Wu Y, Liu D, Zhuang L. MicroRNA-18a-5p represses scar fibroblast proliferation and extracellular matrix deposition through regulating Smad2 expression. Exp Ther Med 2021; 22:1318. [PMID: 34630672 PMCID: PMC8495553 DOI: 10.3892/etm.2021.10753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 11/11/2019] [Indexed: 11/13/2022] Open
Abstract
The aim of the present study was to investigate the expression and role of microRNA-18a-5p (miR-18a-5p) during the formation of hypertrophic scar (HS), and to further explore the molecular mechanisms involved. Downregulation of miR-18a-5p in HS tissues and human HS fibroblasts (hHSFs) was detected by reverse transcription-quantitative polymerase chain reaction. The binding sites between miR-18a-5p and the 3'-untranslated region of SMAD family member 2 (Smad2) were predicted by TargetScan and confirmed by dual-luciferase reporter assay. To investigate the role of miR-18a-5p in HS formation, the effects of miR-18a-5p downregulation or upregulation on hHSFs were subsequently determined. Cell proliferation was detected by an MTT assay, while cell apoptosis was measured by flow cytometry. In addition, the protein expression levels of Smad2, Collagen I (Col I) and Col III were examined by western blot assay. The findings indicated that miR-18a-5p downregulation in hHSFs significantly promoted the cell proliferation, decreased cell apoptosis and enhanced the expression levels of Smad2, Col I and Col III protein and mRNA, whereas miR-18a-5p upregulation in hHSFs exerted opposite effects. Notably, the effects of miR-18a-5p upregulation on hHSFs were eliminated by Smad2 upregulation. In conclusion, the data indicated that miR-18a-5p was downregulated during HS formation, and its upregulation repressed scar fibroblast proliferation and extracellular matrix deposition by targeting Smad2. Therefore, miR-18a-5p may serve as a novel therapeutic target for the treatment of HS.
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Affiliation(s)
- Tianshi Li
- Department of Plastic and Cosmetic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, P.R. China
| | - Yiguang Wu
- Department of Food Science and Engineering, College of Chemistry and Environmental Engineering, Shenzhen University Xili Campus, Shenzhen, Guangdong 518060, P.R. China
| | - Dandan Liu
- Department of Plastic and Cosmetic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, P.R. China
| | - Lida Zhuang
- Department of Plastic and Cosmetic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, P.R. China
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Khor D, Liao J, Fleishhacker Z, Schneider JC, Parry I, Kowalske K, Richard R, Wibbenmeyer L. Update on the practice of splinting during acute burn admission from the ACT study. J Burn Care Res 2021; 43:640-645. [PMID: 34490885 DOI: 10.1093/jbcr/irab161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. METHODS This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant. RESULTS Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). CONCLUSIONS The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.
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Affiliation(s)
- Desmond Khor
- Department of Surgery, University of Iowa Hospitals and Clinics
| | - Junlin Liao
- Department of Surgery, University of Iowa Hospitals and Clinics
| | | | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Spaulding Research Institute, Department of Physical Medicine and Rehabilitation, Harvard Medical School
| | - Ingrid Parry
- Department of Occupational and Physical Therapy, Shriners Hospital for Children, Northern California, University of California, Davis
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern
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Zhu Z, Kong W, Wang H, Xiao Y, Shi Y, Gan L, Sun Y, Tang H, Xia Z. Prevalence and predictors of scar contracture-associated re-hospitalisation among burn inpatients in China. Sci Rep 2021; 11:14973. [PMID: 34294790 PMCID: PMC8298512 DOI: 10.1038/s41598-021-94432-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/09/2021] [Indexed: 11/16/2022] Open
Abstract
Scar contracture, a common destructive complication causing increased re-hospitalisation rate of burn survivors and aggravated burden on the medical system, may be more seriously in Chinese population because of their higher susceptibility to scar formation. This study aims to evaluate the prevalence and predictors of scar contracture-associated re-hospitalisation among Chinese burn inpatients. This cross-sectional study screened burn inpatients hospitalised during 2013 to 2018 through the Hospital Quality Monitoring System database, among whom re-hospitalised for scar contracture were identified. Variables including sex, age, occupations, burn area, burn site and surgical treatment were analysed. Potential predictors of scar contracture-associated re-hospitalisation among burn inpatients were determined by univariate regression analyses. Of the 220,642 burn inpatients, 2146 (0.97%) were re-hospitalised for scar contracture. The re-hospitalised inpatients were predominantly men and blue-collar workers, showing younger median age at the time of burns, larger burn sizes, and higher percentage of surgical treatment compared other burn inpatients. Significant univariate predictors of scar contracture-associated re-hospitalisation included male sex, age < 50 years, blue-collar work, ≥ 40% total body superficial area burned, inhalation injured, and surgical treatment. Scar contracture is an intractable complication and a significant factor to increase re-hospitalisation rate among Chinese burn inpatients.
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Affiliation(s)
- Zhe Zhu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Burn Institute of PLA, Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, 200433, China
| | - Weishi Kong
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Burn Institute of PLA, Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, 200433, China
| | - Haibo Wang
- Clinical Trial Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China.,Centre for Data Science in Health and Medicine, Peking University, Beijing, 100191, China
| | - Yongqiang Xiao
- Department of Burn and Plastic Surgery, The 970Th Hospital of People's Liberation Army, Yantai, 264000, Shandong, China
| | - Ying Shi
- China Standard Medical Information Research Center, 288 Haide 2nd road, Shenzhen, 518000, China
| | - Lanxia Gan
- China Standard Medical Information Research Center, 288 Haide 2nd road, Shenzhen, 518000, China
| | - Yu Sun
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Burn Institute of PLA, Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, 200433, China.
| | - Hongtai Tang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Burn Institute of PLA, Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, 200433, China.
| | - Zhaofan Xia
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Burn Institute of PLA, Research Unit of Key Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, 200433, China.
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Ruppert DS, Mohammed MM, Ibrahim MM, Bachtiar EO, Erning K, Ansari K, Everitt JI, Brown D, Klitzman B, Koshut W, Gall K, Levinson H. Poly(lactide-co-ε-caprolactone) scaffold promotes equivalent tissue integration and supports skin grafts compared to a predicate collagen scaffold. Wound Repair Regen 2021; 29:1035-1050. [PMID: 34129714 DOI: 10.1111/wrr.12951] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/23/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022]
Abstract
Dermal scarring from motor vehicle accidents, severe burns, military blasts, etc. is a major problem affecting over 80 million people worldwide annually, many of whom suffer from debilitating hypertrophic scar contractures. These stiff, shrunken scars limit mobility, impact quality of life, and cost millions of dollars each year in surgical treatment and physical therapy. Current tissue engineered scaffolds have mechanical properties akin to unwounded skin, but these collagen-based scaffolds rapidly degrade over 2 months, premature to dampen contracture occurring 6-12 months after injury. This study demonstrates a tissue engineered scaffold can be manufactured from a slow-degrading viscoelastic copolymer, poly(ι-lactide-co-ε-caprolactone), with physical and mechanical characteristics to promote tissue ingrowth and support skin-grafts. Copolymers were synthesized via ring-opening polymerization. Solvent casting/particulate leaching was used to manufacture 3D porous scaffolds by mixing copolymers with particles in an organic solvent followed by casting into molds and subsequent particle leaching with water. Scaffolds characterized through SEM, micro-CT, and tensile testing confirmed the required thickness, pore size, porosity, modulus, and strength for promoting skin-graft bioincorporation and dampening fibrosis in vivo. Scaffolds were Oxygen Plasma Treatment and collagen coated to encourage cellular proliferation. Porosity ranging from 70% to 90% was investigated in a subcutaneous murine model and found to have no clinical effect on tissue ingrowth. A swine full-thickness skin wound model confirmed through histology and Computer Planimetry that scaffolds promote skin-graft survival, with or without collagen coating, with equal safety and efficacy as a commercially available tissue engineered scaffold. This study validates a scalable method to create poly(ι-lactide-co-ε-caprolactone) scaffolds with appropriate characteristics and confirms in mouse and swine wound models that the scaffolds are safe and effective at supporting skin-grafts. The results of this study have brought us closer towards developing an alternative technology that supports skin grafts with the potential to investigate long-term hypertrophic scar contractures.
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Affiliation(s)
- David S Ruppert
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Mahmoud M Mohammed
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Mohamed M Ibrahim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Emilio O Bachtiar
- Department of Mechanical Engineering and Materials Science, Edmund T. Pratt Jr. School of Engineering, Duke University, Durham, North Carolina, USA
| | - Kevin Erning
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Kayvan Ansari
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Jeffrey I Everitt
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Brown
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Bruce Klitzman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - William Koshut
- Department of Mechanical Engineering and Materials Science, Edmund T. Pratt Jr. School of Engineering, Duke University, Durham, North Carolina, USA
| | - Ken Gall
- Department of Mechanical Engineering and Materials Science, Edmund T. Pratt Jr. School of Engineering, Duke University, Durham, North Carolina, USA
| | - Howard Levinson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, USA.,Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
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Yelvington M, Godleski M, Lee AF, Goverman J, Parry I, Herndon DN, Suman OE, Kowalske K, Holavanahalli R, Gibran NS, Esselman PC, Ryan CM, Schneider JC. Contracture Severity at Hospital Discharge in Children: A Burn Model System Database Study. J Burn Care Res 2021; 42:425-433. [PMID: 33247583 DOI: 10.1093/jbcr/iraa169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.
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Affiliation(s)
| | | | - Austin F Lee
- Massachusetts General Hospital, Boston.,University of Massachusetts Medical School, Worcester
| | - Jeremy Goverman
- Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ingrid Parry
- Shriners Hospital for Children, Northern California/UC Davis Medical Center, Sacramento
| | - David N Herndon
- University of Texas Medical Branch, Shriners Hospitals for Children, Galveston
| | - Oscar E Suman
- University of Texas Southwestern Medical Center, Dallas
| | | | | | | | | | - Colleen M Ryan
- Massachusetts General Hospital, Shriners Hospitals for Children, Boston
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Spaulding Research Institute and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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Hendriks TCC, Botman M, Binnerts JJ, Mtui GS, Nuwass EQ, Niemeijer AS, Mullender MG, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up. Burns 2021; 48:215-227. [PMID: 34716045 DOI: 10.1016/j.burns.2021.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/04/2021] [Accepted: 04/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.
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Affiliation(s)
- T C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands.
| | - M Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | | | - G S Mtui
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - E Q Nuwass
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - M G Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands
| | - H A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - P P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, Location AMC and VUmc, Amsterdam, The Netherlands
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32
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Thomas R, Wicks S, Dale M, Pacey V. Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury. J Burn Care Res 2021; 42:245-257. [PMID: 32820803 DOI: 10.1093/jbcr/iraa137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilized at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Pediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9 months after burn. With intensive physiotherapy, 23 children regained full movement by 12 months after burn. Children who did not achieve complete wound healing at 1 month after burn and children with hypertrophic scarring at 2 months after burn were significantly more represented among cases of early signs of contracture (P = .013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.
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Affiliation(s)
- Rhianydd Thomas
- Department of Health Professions, Macquarie University, North Ryde, New South Wales, Australia.,Burns Unit, The Children's Hospital at Westmead, New South Wales, Australia
| | - Stephanie Wicks
- Burns Unit, The Children's Hospital at Westmead, New South Wales, Australia
| | - Marita Dale
- Discipline of Physiotherapy, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Verity Pacey
- Department of Health Professions, Macquarie University, North Ryde, New South Wales, Australia
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Ma Z, Mo R, Chen C, Meng X, Tan Q. Surgical treatment of joint burn scar contracture: a 10-year single-center experience with long-term outcome evaluation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:303. [PMID: 33708930 PMCID: PMC7944269 DOI: 10.21037/atm-20-4947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Burn patients often have functional problems due to joint scar contracture. Patients suffering from such contracture often experience considerable limitations in daily life. Therefore, surgical treatment is often necessary. Skin grafts, especially full-thickness skin grafts and flaps remain the most commonly used surgical methods in clinical practice. However, there are no clear guidelines stating which technique is the most effective treatment. Herein, we conducted a retrospective cohort study over 10 years of experience at a single center to investigate whether flaps or FTSGs exhibit a better long-term effect. Methods We performed a retrospective chart review of patients with joint burn scar contracture and collected data related to patient demographic profiles, and detailed descriptions of the scars, surgical procedures, and follow-up were collected. We performed follow-up evaluation of three aspects: adverse events (recontracture, ache, and pruritus), satisfaction scores for function and aesthetics, and scar quality (Vancouver Scar Scale score). Results Follow-up results 1 year after surgery from 88 patients were analyzed. In total, 4 (10%) patients in the flap group and 13 (27.1%) patients in the FTSG group had recontracture; the incidence of recontracture was lower in the flap group than in the FTSG group (P=0.043). The functional satisfaction score of the flap group was higher than that of the FTSG group (P=0.027). Moreover, follow-up results 5 year after surgery for 47 patients were analyzed. In total, 1 (4.8%) patient in the flap group and 7 (26.9%) patients in the FTSG group had recontracture; the incidence of recontracture was significantly lower in the flap group than in the FTSG group (P=0.044). The functional satisfaction score in the flap group was higher than that of the FTSG group (P=0.041). In this study, no significant differences in scar quality were observed between the two groups. Conclusions If conditions permit, the application of different types of flaps may represent a better choice than FTSGs in terms of reducing the recontracture rate and improving joint function.
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Affiliation(s)
- Zhouji Ma
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Ran Mo
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Chen Chen
- Department of Nutrition, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Xueyong Meng
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Qian Tan
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
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Hendriks TCC, Botman M, de Haas LEM, Mtui GS, Nuwass EQ, Jaspers MEH, Niemeijer AS, Nieuwenhuis MK, Winters HAH, van Zuijlen PPM. Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country. Burns 2021; 47:1285-1294. [PMID: 33485727 DOI: 10.1016/j.burns.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/10/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.
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Affiliation(s)
- T C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Haydom Lutheran Hospital, Haydom, Tanzania; Amsterdam Public Health Research Institute, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands.
| | - M Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | - L E M de Haas
- Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | - G S Mtui
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - E Q Nuwass
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - M E H Jaspers
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - A S Niemeijer
- Burn Center, Martini Hospital, Groningen, The Netherlands; Association of Dutch Burn Centers, The Netherlands
| | - M K Nieuwenhuis
- Burn Center, Martini Hospital, Groningen, The Netherlands; Association of Dutch Burn Centers, The Netherlands
| | - H A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - P P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Amsterdam Movement Sciences, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Paediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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The Impact of Fibrin Sealant Volume on Skin Graft Contraction in a Full-Thickness Skin Graft Model. J Craniofac Surg 2020; 31:2156-2159. [PMID: 33136846 DOI: 10.1097/scs.0000000000006629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Fibrin sealant has been used for skin grafting in anatomically difficult facial areas. Although biodegradable, an excess of fibrin sealant may inhibit skin graft healing by inhibiting diffusion at the graft-recipient bed interface. The impact of fibrin sealant volume on graft healing was examined in a rat full-thickness skin graft model. METHODS Seventy-two full-thickness 2.5 × 2.5-cm skin grafts were used on the dorsum of male Sprague-Dawley rats. The grafts were treated with three different volumes of fibrin sealant placed onto the recipient bed: 0.0 mL or normal saline (group 1), 0.1 mL (group 2), and 0.4 mL (group 3). Graft healing and complications were assessed using digital photographs and necropsies on postoperative days 3, 7, and 21. RESULTS Group 3 showed the greatest graft contraction on days 3 and 21, while group 2 showed the least contraction on all 3 postoperative days (P = 0.002, 0.004, and <0.001, respectively). Histopathologic analysis showed inflammatory foreign body reactions in group 3 on days 3 and 7, and less vascular density on day 21 (P = 0.003). Group 1 showed the highest incidence of hematoma (P = 0.004). CONCLUSION An excess volume of fibrin sealant may produce pathologic wound contraction in skin grafting because a skin graft lacks a vascular pedicle and is highly dependent on diffusion from the host environment. Before using fibrin sealant for skin grafting in facial areas where the aesthetic outcome is important, the appropriate volume to use can be determined.
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Maitz J, Wang Y, Fathi A, Ximena Escobar F, Parungao R, van Zuijlen P, Maitz P, Li Z. The effects of cross-linking a collagen-elastin dermal template on scaffold bio-stability and degradation. J Tissue Eng Regen Med 2020; 14:1189-1200. [PMID: 32721107 DOI: 10.1002/term.3082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 12/18/2022]
Abstract
MatriDerm is a collagen-elastin dermal template that promotes regeneration in full-thickness wound repair. Due to its noncross-linked status, MatriDerm biodegrades quickly in a wound. Facilitating vascularization and dermal repair, it is desirable for MatriDerm to remain present until the wound healing process is complete, optimizing tissue regeneration and reducing wound contraction. The aim of this study was to investigate the effect of cross-linking MatriDerm on its mechanical and biological properties and to enhance its regenerative functionality. MatriDerm was chemically cross-linked and characterized in comparison with noncross-linked MatriDerm. Scaffold properties including surface morphology, protein release and mechanical strength were assessed. Cell-scaffold interaction, cell proliferation and migration were examined using human dermal fibroblasts. Scaffold biodegradation and its impact on wound healing and contraction were studied in a mouse model. Results showed that cross-linked MatriDerm displayed a small reduction in pore size, significantly less protein loss and a threefold increase in tensile strength. A significant increase in fibroblast proliferation and migration was observed in cross-linked MatriDerm with reduced scaffold contraction in vitro. In the mouse model, noncross-linked MatriDerm was almost completely biodegraded after 14 days whereas cross-linked MatriDerm remained intact. No significant difference in wound contraction was found between scaffolds. In conclusion, cross-linked MatriDerm showed a significant increase in stability and strength, enhancing its durability and cell-scaffold interaction. in vivo analysis showed cross-linked MatriDerm had a reduced biodegradation rate with a similar host response. The extended structural integrity of cross-linked MatriDerm could potentially facilitate improved skin tissue regeneration, promoting the formation of a more pliable scar.
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Affiliation(s)
- Joanneke Maitz
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia
| | - Yiwei Wang
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia.,Disciplines of Surgery, University of Sydney Concord Clinical School, Concord, New South Wales, Australia
| | - Ali Fathi
- Faculty of Engineering and Information Technologies, University of Sydney, Camperdown, New South Wales, Australia
| | - Francia Ximena Escobar
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia
| | - Roxanne Parungao
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia
| | - Paul van Zuijlen
- Burn Centre and Dept. of Plastic and Reconstructive Surgery, Red Cross Hospital, Beverwijk, the Netherlands.,Amsterdam Movement Sciences, Amsterdam UMC, Amsterdam, NH, the Netherlands
| | - Peter Maitz
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia.,Burns Unit, Concord Hospital, Concord, New South Wales, Australia.,Disciplines of Surgery, University of Sydney Concord Clinical School, Concord, New South Wales, Australia
| | - Zhe Li
- Burn Injury and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord, New South Wales, Australia.,Burns Unit, Concord Hospital, Concord, New South Wales, Australia.,Disciplines of Surgery, University of Sydney Concord Clinical School, Concord, New South Wales, Australia
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The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2907. [PMID: 32802643 PMCID: PMC7413812 DOI: 10.1097/gox.0000000000002907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC.
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Zhou J, Zhao Y, Yang W, Du Q, Yin J, Gu Y, Hao C. Use of Mechanical Stretching to Treat Skin Graft Contracture. J Burn Care Res 2020; 41:892-899. [PMID: 32112091 DOI: 10.1093/jbcr/iraa033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
After transplantation, skin grafts contract to different degrees, thus affecting the appearance and function of the skin graft sites. The exact mechanism of contracture after skin grafting remains unclear, and reliable treatment measures are lacking; therefore, new treatment methods must be identified. Many types of centripetal contraction forces affect skin graft operation, thus leading to centripetal contracture. Therefore, antagonizing the centripetal contraction of skin grafts may be a feasible method to intervene in skin contracture. Here, the authors propose the first reported mechanical stretching method to address contracture after skin grafting. A full-thickness skin graft model was established on the backs of SD rats. The skin in the experimental group was stretched unilaterally or bidirectionally with a self-made elastic stretching device, whereas the skin was non-stretched in the control group. The rats were sacrificed 2 weeks after stretching. The area, length, and width of the skin were measured. The grafts were cut and fixed with formalin. Routine paraffin sections were stained with hematoxylin-eosin, picric acid-Sirius red, Victoria blue, and anti-alpha-smooth muscle actin (SMA). Mechanical stretching made the graft lengthen in the direction of the stress and had an important influence on collagen deposition and alpha-SMA expression in the graft. This method warrants further in-depth study to provide a basis for clinical application.
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Affiliation(s)
- Jinfeng Zhou
- Department of Burn and Plastic Surgery, Nanjing, Jiangsu, China
| | - Youcai Zhao
- Department of Pathology, Nanjing, Jiangsu, China
| | - Wengbo Yang
- Department of Orthopaedics, Nanjing, Jiangsu, China
| | - Qianming Du
- Central Laboratory, the Affiliated Nanjing Hospital of Nanjing Medical University (Nanjing First Hospital), Nanjing, Jiangsu, China
| | - Jun Yin
- Department of Burn and Plastic Surgery, Nanjing, Jiangsu, China
| | - Yanqing Gu
- Department of Orthopaedics, Nanjing, Jiangsu, China
| | - Chao Hao
- Department of Burn and Plastic Surgery, Nanjing, Jiangsu, China
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The Safety and Efficacy of Intralesional Verapamil Versus Intralesional Triamcinolone Acetonide for Keloids and Hypertrophic Scars: A Systematic Review and Meta-analysis. Adv Skin Wound Care 2020; 33:1-7. [DOI: 10.1097/01.asw.0000655476.10403.d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pham TN, Goldstein R, Carrougher GJ, Gibran NS, Goverman J, Esselman PC, Kazis LE, Ryan CM, Schneider JC. The impact of discharge contracture on return to work after burn injury: A Burn Model System investigation. Burns 2020; 46:539-545. [PMID: 32088093 DOI: 10.1016/j.burns.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/22/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury. METHODS We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months. RESULTS A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months. CONCLUSIONS This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients.
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Affiliation(s)
- Tam N Pham
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, United States.
| | - Richard Goldstein
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, United States
| | - Gretchen J Carrougher
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, United States
| | - Nicole S Gibran
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, United States
| | - Jeremy Goverman
- Shriners Hospitals for Children-Boston, Department of Surgery, Harvard Medical School, United States
| | - Peter C Esselman
- Department of Rehabilitation Medicine, University of Washington, United States
| | - Lewis E Kazis
- Department of Health Law and Policy and Management, Boston University School of Public Health, United States
| | - Colleen M Ryan
- Shriners Hospitals for Children-Boston, Department of Surgery, Harvard Medical School, United States
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, United States
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Lensing J, Wibbenmeyer L, Liao J, Parry I, Kowalske K, Reg R, Schneider JC. Demographic and Burn Injury-Specific Variables Associated with Limited Joint Mobility at Discharge in a Multicenter Study. J Burn Care Res 2020; 41:363-370. [DOI: 10.1093/jbcr/irz174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Burn scar contractures. Existing research on contractures is limited by incomplete analysis of potential contributing variables and differing protocols. This study expands the exploration of contributing variables to include surgery and rehabilitation treatment-related factors. Additionally, this study quantifies direct patient therapy time and patient exposure to rehabilitation prevention therapies. Data from subjects enrolled in the prospective Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) were analyzed to determine variables related to a limited range of motion (limROM) in seven joints and 18 motions (forearm supination) at discharge. Chi-squared and Student’s t-test were used accordingly. Multivariate analysis was performed at the patient and joint motion level to control for confounders. Of the 300-member study group, 259 (86.3%) patients had limROM at discharge. Variables independently related to the development of moderate-to-severe limROM on the patient level were larger TBSA, having skin grafted and prolonged bed rest. Variables independently related to moderate–severe limROM on the joint motion level were the percentage of cutaneous functional unit (CFU) burned (P = .044), increase in the length of stay, weight gain, poor compliance with rehabilitation therapy and lower extremity joint burns. Rates of limROM are increased in patients who had larger burns, required surgery, had a greater percentage of the associated CFU burned, and had lower extremity burns. Attention to adequate pain control to ensure rehabilitation tolerance and early ambulation may also decrease limROM at discharge and quicker return to pre-burn activities and employment.
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Affiliation(s)
- Jonathan Lensing
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Lucy Wibbenmeyer
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Junlin Liao
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Ingrid Parry
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Karen Kowalske
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Richard Reg
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Jeffrey C Schneider
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
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Course of prevalence of scar contractures limiting function: A preliminary study in children and adolescents after burns. Burns 2019; 45:1810-1818. [DOI: 10.1016/j.burns.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/28/2019] [Accepted: 05/01/2019] [Indexed: 10/25/2022]
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Oosterwijk AM, Disseldorp LM, van der Schans CP, Mouton LJ, Nieuwenhuis MK. Joint flexibility problems and the impact of its operationalisation. Burns 2019; 45:1819-1826. [PMID: 31679794 DOI: 10.1016/j.burns.2019.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 12/08/2018] [Accepted: 03/03/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Dissatisfaction is being voiced with the generally used way joint flexibility problems are defined (operationalised), i.e. as a range of motion (ROM) one or more degrees lower than normative ROM of healthy subjects. Other, specifically more function-related operationalisations have been proposed. The current study evaluated the effect of applying different operationalisations of joint flexibility problems on its prevalence. METHOD ROM data of 95 joints affected by burns of 23 children were used, and data on 18 functional activities (Burn Outcome Questionnaire (BOQ)). Five methods were used to operationalise joint flexibility problems: (1) ROM below normative ROM, (2) ROM below normative ROM minus 1SD, (3) ROM below normative ROM minus 2SD, (4) ROM below functional ROM, and (5) a score of 2 or more on the Likert Scale (BOQ). RESULTS Prevalence of joint flexibility problems on a group level ranged from 13 to 100% depending on the operationalisation used. Per joint and movement direction, prevalence ranged from 40% to 100% (Method 1) and 0% to 80% (Methods 2-4). 18% of the children received '2' on the Likert Scale (Method 5). CONCLUSION The operationalisation of joint flexibility problems substantially influences prevalence, both on group and joint level. Changing to a function-related operationalisation seems valuable; however, international consensus is required regarding its adoption. TRIAL REGISTRATION The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).
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Affiliation(s)
- A M Oosterwijk
- Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Het Wiebenga, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands; Association of Dutch Burn Centres, Burn Centre Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - L M Disseldorp
- Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Het Wiebenga, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands; Association of Dutch Burn Centres, Burn Centre Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Health Psychology, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
| | - C P van der Schans
- Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Het Wiebenga, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Health Psychology, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - L J Mouton
- University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
| | - M K Nieuwenhuis
- Association of Dutch Burn Centres, Burn Centre Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
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45
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Effectiveness of Paraffin and Sustained Stretch in Treatment of Shoulder Contractures Following a Burn Injury. Arch Phys Med Rehabil 2019; 101:S42-S49. [PMID: 31562875 DOI: 10.1016/j.apmr.2019.08.482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/05/2019] [Accepted: 08/22/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine if range of motion of the shoulder treated with paraffin will be better than that of the shoulder treated with sustained stretch alone. DESIGN Pilot randomized controlled trial. SETTING Regional burn center. PARTICIPANTS Patients (N=23) who sustained a burn injury, with a shoulder active abduction and/or flexion in the +70° to +150° degree range, who were 14 years or older, were receiving follow-up physical therapy after discharge from hospital, and provided a signed consent to participate. INTERVENTIONS Group A received sustained stretch and paraffin, and group B received sustained stretch only. Both groups had 6 sessions of treatment over 2 weeks. MAIN OUTCOME MEASURES Active range of motion (AROM) and active-assisted range of motion (AAROM) for shoulder flexion (SF) and shoulder abduction (SA) were measured before and after each treatment session. RESULTS For pretreatment measurements, only the results for SF AAROM had significant time effects. For posttreatment measurements, SF AROM and SF AAROM had significant effects for time. Session 1 was significantly lower than sessions 2, 3, 4, and 6 for both measures, and additionally, session 1 was significantly lower than session 5 for SF AAROM. For SA AROM, a group-by-time interaction effect was significant, with scores for the paraffin group relatively stable across sessions, and the nonparaffin group had peaks at sessions 3 and 6. There were no significant effects for (1) within-session changes to examine improvement during a session or (2) presession scores across the 6 sessions showing maintenance of motion. Total change from the first session presession measurement to the sixth session postsession measurement for the 2 treatment groups were nonsignificantly different. CONCLUSIONS As shown in this study, sustained stretching with paraffin may be a valuable adjunct to range of motion intervention for the shoulder after burn injury.
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Deng H, Li-Tsang CW. Measurement of vascularity in the scar: A systematic review. Burns 2019; 45:1253-1265. [DOI: 10.1016/j.burns.2018.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 06/28/2018] [Accepted: 10/31/2018] [Indexed: 01/24/2023]
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47
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Boffeli TJ, Gorman CM. Achilles Lengthening and Multiple Z-Plasty in Parallel for Correction of Toe Walking Associated With Burn Scar Equinus Contracture. J Foot Ankle Surg 2019; 58:1025-1029. [PMID: 31474392 DOI: 10.1053/j.jfas.2019.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 02/03/2023]
Abstract
The literature is sparse regarding treatment of burn scar equinus contracture, with focus primarily on staged procedures, serial casting, and gradual correction using external fixation in combination with soft-tissue procedures. This case study describes a single-stage ambulatory approach for late-stage correction of burn scar equinus contracture associated with toe walking. A case report is presented of an 11-year-old male with focus on procedure selection, surgical technique, and 12-month follow-up results. Surgery involved a single-stage approach with open Achilles lengthening, in addition to multiple skin Z-plasty in parallel with immediate protected weightbearing to correct toe walking. Inadequate release of contracture was noted intraoperatively after Achilles lengthening. Full correction was achieved after converting the longitudinal incision into multiple Z-plasty in parallel, with full heel purchase at 2 weeks postoperatively. The patient was completely healed with pain-free range of motion at 6 weeks postoperatively. At 12 months postoperatively, he continued to ambulate normally without overcorrection or recurrence of deformity. This case study describes a late-stage, minimally invasive, single-stage approach to correction of burn scar equinus contracture. The surgical principles and technique are described. Allowance of immediate weightbearing was possible because all other burn wounds were healed at late-stage presentation that avoided the need for gradual correction with external fixation or serial procedures.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN
| | - Catlea M Gorman
- Chief Resident, Foot & Ankle Surgery, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN.
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Thomas R, Wicks S, Toose C, Pacey V. Outcomes of Early Use of an End of Range Axilla Orthotic in Children Following Burn Injury. J Burn Care Res 2019; 40:678-688. [PMID: 30950500 DOI: 10.1093/jbcr/irz058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Scar contracture is a significant complication of burn injury. This study aimed to describe outcomes of early axilla orthotic use at end of range abduction in children, following a burn to the axilla region. A retrospective review of 76 children (mean age 3.9 years [SD 3.6]) treated at a tertiary children's hospital from 2006 to 2016 was conducted. No child developed axilla contracture for the duration of the 2-year study follow-up with no adverse events recorded. If orthotic use was ceased <60 days post-burn, it was considered not an essential intervention to maintain range of movement, leaving 49 children using the orthotic ≥60 days. Compared with the children who ceased orthotic use in <60 days, children who required the orthotic ≥60 days had a significantly higher frequency of deep-dermal burn (59 vs 25%, p = .01), flame mechanism (25 vs 5%, p = .03), and burn injury distribution involving the anterior trunk, flank, and arm (18 vs 3%, p = .03). Early signs of contracture, considered loss of full axilla range or significant banding, developed in nine children within 3 months post-burn. With intensive therapy, all returned to full axilla range by 9 months post-burn. Children with skin tension at end of range shoulder movement at the 1-month clinical assessment were 11 times more likely to develop early signs of contracture (95% confidence interval [CI]: 1.9-62.1, p = .007). Intensive orthotic use at end of range shoulder abduction in children with axilla burns is well tolerated. When undertaken with ongoing therapist review, full axilla range can be maintained.
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Affiliation(s)
- Rhianydd Thomas
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia.,Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Stephanie Wicks
- Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Claire Toose
- Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Verity Pacey
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
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49
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Interrupting the seams: The principle of preventive burn reconstruction. BURNS OPEN 2019. [DOI: 10.1016/j.burnso.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Maarof M, Mh Busra MF, Lokanathan Y, Bt Hj Idrus R, Rajab NF, Chowdhury SR. Safety and efficacy of dermal fibroblast conditioned medium (DFCM) fortified collagen hydrogel as acellular 3D skin patch. Drug Deliv Transl Res 2019; 9:144-161. [PMID: 30547385 DOI: 10.1007/s13346-018-00612-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Skin substitutes are one of the main treatments for skin loss, and a skin substitute that is readily available would be the best treatment option. However, most cell-based skin substitutes require long production times, and therefore, patients endure long waiting times. The proteins secreted from the cells and tissues play vital roles in promoting wound healing. Thus, we aimed to develop an acellular three-dimensional (3D) skin patch with dermal fibroblast conditioned medium (DFCM) and collagen hydrogel for immediate treatment of skin loss. Fibroblasts from human skin samples were cultured using serum-free keratinocyte-specific media (KM1 or KM2) and serum-free fibroblast-specific medium (FM) to obtain DFCM-KM1, DFCM-KM2, and DFCM-FM, respectively. The acellular 3D skin patch was soft, semi-solid, and translucent. Collagen mixed with DFCM-KM1 and DFCM-KM2 showed higher protein release compared to collagen plus DFCM-FM. In vitro and in vivo testing revealed that DFCM and collagen hydrogel did not induce an immune response. The implantation of the 3D skin patch with or without DFCM on the dorsum of BALB/c mice demonstrated a significantly faster healing rate compared to the no-treatment group 7 days after implantation, and all groups had complete re-epithelialization at day 17. Histological analysis confirmed the structure and integrity of the regenerated skin, with positive expression of cytokeratin 14 and type I collagen in the epidermal and dermal layer, respectively. These findings highlight the possibility of using fibroblast secretory factors together with collagen hydrogel in an acellular 3D skin patch that can be used allogeneically for immediate treatment of full-thickness skin loss.
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Affiliation(s)
- Manira Maarof
- Tissue Engineering Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaccob Latiff, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Mohd Fauzi Mh Busra
- Tissue Engineering Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaccob Latiff, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Yogeswaran Lokanathan
- Tissue Engineering Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaccob Latiff, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Ruszymah Bt Hj Idrus
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaccob Latiff, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Nor Fadilah Rajab
- Bioserasi Laboratory, Universiti Kebangsaan Malaysia, 43600, Bangi, Selangor Darul Ehsan, Malaysia
| | - Shiplu Roy Chowdhury
- Tissue Engineering Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaccob Latiff, Cheras, 56000, Kuala Lumpur, Malaysia.
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